Responsive Respiratory

For Processing Fax Application to:  1-866-333-4035

• Federal Tax ID #:  __________________
• Company/Parent Name: ________________________________________    Years in Business:  _____
• Billing Address:________________________________       City:_____________ State:_____   Zip:_________
• Shipping Address:______________________________       City:_____________ State:_____   Zip:_________
• Phone:_____________________  Fax:____________________  Accounting contact: ______________________
• Type of Business        Corporation               Partnership          Branch of ________________

Trade References                                                                  Fax numbers required to process application

Name	Account #	Address, City, State, Zip	Fax #	Phone# + Contact

 Bank References                                                                                            Fax numbers required to process application

Name	Account #	Address, City, State, Zip	Fax #	Phone# + Contact

Proprietors, Partners or Officers                                             

Name	Position	Social Security #

 Anticipated Monthly Purchases: ______________

Sales Tax Exemption Certificate # _________________ Certificate shall be considered a part of each order, unless otherwise specified.

Responsive Respiratory notifies its customers via Email when shipments are made.  We also utilize your fax number to notify you on our specials and promotional programs.  If you do not wish to receive this information please check the appropriate box.    Yes, please notify  No, do not notify    Email: (purchasing dept.) ___________

I certify the information in this application is correct and I grant authority to Responsive Respiratory or their representative to obtain credit information from any source listed, including my bank.  All information will be held in strict confidence.  If credit is granted (I)(we) promise to pay bills according to terms.  Responsive Respiratory reserves the right to assess a late charge of 1 ½% per month on balance past due.  In the event payment is not made and (my)(our) account is referred to a collection agency, (I)(we) will pay all costs of collection.  If legal action is required (I)(we) will pay reasonable attorney’s fees resulting from such action. The person executing this agreement has authority to bind the customer.

    Signature:     _________________________________   Date:    _________

    Name:           ________________________________    Title:     _________